health insurance

[snowman45106]

What is the name of your state (only U.S. law)? az

Can anyone tell me, my wife was in admitted into a hospital that was out of network. The insurance company oked it. The doctor accepted it and the hospital accepted her. the problem now is the insurance company is refusing to pay their share of the bill because of the hospital being out of network and the have know this all along. We just got a bill for 27000 dollars for her 3 hour stay in the hospital for out-patient surgery. What can we do?

 

[Proserpina]

What is the name of your state (only U.S. law)? az

Can anyone tell me, my wife was in admitted into a hospital that was out of network. The insurance company oked it. The doctor accepted it and the hospital accepted her. the problem now is the insurance company is refusing to pay their share of the bill because of the hospital being out of network and the have know this all along. We just got a bill for 27000 dollars for her 3 hour stay in the hospital for out-patient surgery. What can we do?

Was it pre-authorized? Very often what happens is the hospital itself might be in-network, but that doesn't mean that the providers are also in-network.

 

[ecmst12]

Authorizing care as medically necessary does not mean they agree to cover services as if they were in network when they're not. If she was admitted through the ER, then it should be covered, but if this was a planned admission, she should have used a covered facility. If your plan has out of network benefits, it will be covered at that level.

 

[snowman45106]

Was it pre-authorized? Very often what happens is the hospital itself might be in-network, but that doesn't mean that the providers are also in-network.

She was preapproved by everyone including the insurance company, her doctor and the hospital before being admitted.

 

[cbg]

Once again, pre-approving a medical treatment is not a guarantee of in-network benefits at an out of network hospital. If you believed it was, you were mistaken.

 

[commentator]

There is some kind of appeal process. If there was a valid reason why this particular hospital was used, you can certainly appeal the decision before you set out paying the money. While the "shock value" of receiving a bill this high, which believe me, I've gotten a few like this in my day, can be scary, it's usually not as bad as it looks at the beginning. Examine the details in your policy, work with them to appeal, negotiate. Yes, that they pre approved it doesn't mean they have to pay it, that they won't deny it at this point, but it does help in the appeals process that you did use all the right steps and took reasonable action to make sure the facility would be approved and your insurance was okay with it.

 

[ecmst12]

You can't really appeal an out of network decision unless there was absolutely no in network hospital available within a reasonable distance, or it was an emergency admission.